1. Osteomyelitis Reşat ÖZARAS, MD, Prof. Infection Dept. rozaras@yahoo.com rozaras@yahoo.com

2. OSTEOMYELITIS Infection of bone marrow and and adjacent bone Several classifications

3. The duration of the disease Acute osteomyelitis Subacute osteomyelitis Chronic osteomyelitis

4. The way of occurence 1 - Hematogenous osteomyelitis 2 – Osteomyelitis secondary to direct transmission - Any vascular disease may/not associate 3 - Chronic osteomyelitis (necrotic bone)

6. Anatomical classification Stage 1: medullary osteomyelitis Stage 2: superficial osteomyelitis Stage 3: localized osteomyelitis Stage 4: diffuse osteomyelitis

7. SYSTEMIC AND LOCAL FACTORS Systemic Local Malnutrition Chronic lymphedema Renal, hepatic failure Venous failure Diabetes mellitus Vascular insufficiency Chronic hipoxia Arteritis Alcohol and/or tobacco use Tissue scar Malignant disorders Radiation fibrosis Advanced age Neuropathy Immune suppression HIV/AIDS

9. ETIOLOGY Babies (<1 year) Group B streptococci S. aureus E. coli Children (1 - 16 years) S. aureus S. pyogenes H. influenzae Adult(> 16 years) S. epidermidis S. aureus P. aeruginosa

10. EPIDEMIOLOGY Acute hematogenous osteomyelitis: a disorder of childhood period A trend to increase: traffic accidents, increasing rates of orthopedic interventions. Adults– Vertebtal osteomyelitis (Spondylodiscitis)

12. CLINICAL FEATURES Acute Hematogenous Osteomyelitis - Systemic disorder - No structural bone changes - A history of less than 10 days - No previous episodes Subacute Hemotogenous Osteomyelitis -Systemic disorder (not as severe as the acute form) -Bone changes -A history of more than 10 days - No previous episodes Chronic osteomyelitis -Systemic disorder may/not associate -Bone changes - There is/are previous episode(s).

13. Clinical Features Depends on the way of development (hematogenous, direct, from adjacent tissues), patient's characteristics and the period of the disorder Hematogenous osteomyelitis – fever, fatigue, restlessness – Tenderness, pain, and edema on the affected site – Decreased mobility of the affected extremity – Muscle spasms

14. From adjacent tissue; pain, redness, swellings, a draining sinus from the site of trauma, wound, or operation Dorsal/back pain in vertebral osteomyelitis.

15. RADIOLOGICAL FINDINGS Plain X-ray; Diagnosis and the course of the disease Increase in density of the surrounding soft tissues (first 10 days) Periostal reaction (after 10 days) Bone loss in subacute period

17. Bone scan For early diagnosis

18. Computed tomography Sentitive for soft tissue inflammation as well. Diagnosis and follow-up of the therapy

19. Magnetic Resonance Soft tissue and bone marrow inflammation Early diagnosis

20. Differential Diagnosis Rheumatic fever Cellulitis Ewing’s sacroma Septic arthritis Osteosarcoma Eosinophilic granuloma Thrombophlebitis

21. Vertebral Osteomyelitis Frequent etiology: – S. aureus, – M. tuberculosis, – Brucella Gram-negative bacilli (Gastrointestinal or urinary system) Postoperative Pain and disability May be indolent and fever may not be seen

22. Tx Antibiotics Surgery Underlying disorder

23. Meticilin-sensitive Staph. → Cefazolin or Sulbactam/ampicillin Meticilin-resistant Staph →Vancomycin or teicoplanin Brucella → Rifampin+doxycycline Tuberculosis → INH+RIF+PZA+EMB Antibiotics

26. Etiology N (%) Pyogenic44 Post-op10 Others34 Brucella24 Tuberculosis32 Total100

27. Pyogenic MicroorganismCases (%) Gram-positive Staphylococcus aureus (endocarditis) Gram-negative Pseudomonas aeruginosa Enterobacter cloacae Salmonella enteritidis Escherichia coli Fungus 13 1 2 1

28. Children: Acute hematogenous Adult: Chronic (hematogenous---from adjacent tissues…